17t12 Nonimmigrant Visa - Confirmation Page

Online Nonirmnigrant Visa Application (DS- 160)

Confirmation

This confirms the submission of the Nonimmigrant visa application for:

Photo notFrouid ed

NameProvided:

Date Of Birth:

Place ofBirth:

Gender:

Nationality:

PassportNumber:

Purpose ofTravel:

CompletedOn:

ConfirmationNo:

MOISEI, PARASCOVIA

27 oCT 1990

BAIMACLIA, MOLDOVA

Female

MOLDOVA

A2752664

TOURISM/MEDICALTREATMENT (82)

07 MAR 2012

AAOO26TTCL

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Location Selected:

cHsEmbassy of the United StatesAmerica1O3 Mateevici StreetChisinau MD-2OO9Republic of Moldova

Version 01.01.03

of

THIS TS NOT A VLqA

YOU MUST BRING this confirmation page and the following document(s) with you to the Application Service Center:

Passport

You may also provide any additional documents you feel will support your case.

yOU MUST SUBMIT this confirmation page with a clear and legible barcode at the time of your interview. If you do not have accessto a printer atthis time, select the option to email your conflrmation page to an email address. You may print or email yourapplication for your own records. YOU DO NOT need to submit the application at the time of the interview.

please note that you will be required to provide proof that you have paid the visa application fee and any other fees associated withyour application. There may be other fees associated with the visa application process. Please check your country's ReciprociwSchedule for any other fees you may owe.

Ifyouhavefurtherquestions,ortofindoUthowtocontacttheConsularPost,pleasegoto@orhttp : //travel.state.oov .

@ittedwithyourvisaapplicationdidnotmeetthequalitystandardSspecifiedintheinstrUctionsonsubmission ior visa applicants. Please have new photos taken, specifically following the photo guideline instructions on

NOTE: Unless exempt from an interview, you will be required to sign your application by providing a biometric signature, i.e' yourfingerprint before a consular officer, By pioviding this biometric signature you are certifying under penalty of perjury that you haveread and understood the questions in your nonimmigrant visa application and that all statements that appear in your nonimmigrantvisa application have been made by you and are true and complete to the best of your knowledge and belief.. Furthermore at thetime of your interview, you will be required to certify under penalty of perjury that all statements in your application and thosemade during your interview are true and compete to the best of your knowledge and belief.

ttps://ceac.state.gov/GENNIV/general/esign/complete-done.aspx?node=Done

Online Noninnnigrant Visa Applbation (DS- 160)

Applic ation - Sensitiv'e But Unc lassified( SBU)

Only print this application for your records. Youduring your interview process.

Consular Electronic Application Center - Print Application

will not be permitted to submit a printed copy of your application

Photo Provided:

Fhoto nstFrocided

Confirmation Number:

AABO26TTCL

Personal, Address, Phone, and Passport/Travel

Name Provided:

Full Name in Native Language:

Other Names Used:

Telecode Name Used:

Sex:

Marital Status:

Date of Birth:

Place of Birth:

Nationality:

Other Nationalities:

National Identification Number:

U.S. Social Security Number:

U.s. Taxpayer ID Number;

Home Address:

CitY:

State/Province:

Postal ZonelZIP Code:

C ountry:

Same Mailing Address?

Primary Phone Number:

Secondary Phone Number:

Document Information

r ffiril ilfiililffir ililr il]l ffi fl lffi il|il I llil

MOISEI, PARASCOVIA

DOES NOT APPLY

NO

NO

FEMALE

SINGLE

27 oCTOBER 1990

BAIMACLIA, CANTEMIR, MOLDOVA

MOLDOVA

NO

DOES NOT APPLY

DOES NOT APPLY

DOES NOT APPLY

S.BAIMAC LIA R,CANTEMIR

BAIMACLIA

CANTEMIR

DOES NOT APPLY

MOLDOVA

YES

27343420

DOES NOT APPLY

ttps:/lceac.state.gov/GENNIV/commonlprintapplication.aspx?P'l Hr0dJwcnnROkwztqqlMWOMOxukFd

nh2Work Phone Number:

Email Address:

Consular Electronic Application Center - Print Application

DOES NOT APPLY

pashuta 15@yahoo.com

REGULAR

42752664

DOES NOT APPLY

MOLDOVA

CANTEMIR

MOLDOVA

28 DECEMBER 2006

28 DECEMBER 2016

NO

TEMP. BUSINESS PLEASURE VISITOR

TOURISM/MEDICAL TREATMENT (B2)

07 MAY 2012

2 WEEK(S)

23.30 31 AVENUE

ASTORIA, NEW YORK 11106

SELF

YES

NO

MOISEI, VASILE

PARENT

MOISEI, ANA

PARENT

YES

09 JUNE 2011

3 MONTH(S)

NO

YES

18 MAY 2011

E3568743

NO

YES

Passpoftrlravel Document Type :

Passpoffiravel Document Number:

Passport Book Number:

C ountry/Authority that Issued Passport/travel Docume nt:

City Where Issued:

Country Where Issued:

Issuance Date:

Expiration Date:

Have you ever lost a passport or had one stolen?

Travel Information

i{ fnu List of Purposes of Trip to the U.s.

Purpose of Trip to the U.S. (1):

Specify:

Intended Date of Arrival:

Intended Length of Stay in U.S.:

Address where you will stay in the U.S.:

City, State, Postal/Zip Code:

Person/Entity Paying for Your Trip:

Are there other persons traveling with you?

Are you traveling as part of a group or organization?

id P.rront Traveling with You:

Name (1):

Relationship to You:

Name (2):

Relationship to You:

fd nur" you ever been in the u.s.?

Provide information on your last five U.S. visits:

Date Arrived (1):

Length of Stay:

Do you or did you hold a U.S. Driver's License?

l{ nur" you ever been issued a U.S. Visa?

Date Last Visa was Issued:

Visa Number:

Are you applying for the same type of visa?

Are you applying in the same country where the visa above is issuedand is this country your principal country of residence?

Have you been ten-printed?

Has your U.S. Visa ever been lost or stolen?

(B)

NO

NO

2lttps:/lceac.state.gov/GENN|V/common/printapplication.aspx?Pl HOdJwcnnROkwztqqlMWOMOxukFd...

ft112 Consular Electronic Application Center - Print Application

Has your U.S. Visa ever been cancelled or revoked? NO

Have you ever been refused a U.S. Visa, been refused admission to NOthe United States, or withdrawn your application for admission at theport of entry?

Has anyone ever filed an immigrant petition on your behalf with the NO

United States Citizenship and Immigration Services?

U.S. Contact Information

Contact Person Name in the U.S.: CANAZIR DROBENKO, VIORICA

Organization Name in the U.S.: DO NOT KNOW

Relationship to You: RELATIVE

U.S. Contact Address: 23-30 31 AVENUE

ASTORIA, NEW YORK 11106

Phone Number: $46)436-7869

Email Address: johnandviorica@gmail.com

Family Information

Father's Surnames: MOISEI

Father's Given Names: VASILE

Father's Date of Birth: 05 APRIL 1965

Is your father in the U.S.? NO

Mother's Surnames: MOISEI

Mother's Given Names' ANA

Mother's Date of Birth: 14 IULY 1969

Is your mother in the U.S.? NO

Do you have any immediate relatives, not including parents in the NO

U,S.?

Do you have any other relatives in the United States? YES

Work/ Education/Tra ining Information

Primary Occupation: STUDENT

Present Employer or School Name: UNIVERSITATEA LIVERA INTERNATIONALA DINMOLDOVA ULIM ANUL 3 DE STUDII

AddTesS: 52 VLAICU PARCALAB STREET

City: CHISINAU

State/Province: DOES NOT APPLY

Postal ZonelZip Code: MD-2012

Countryr MOLDOVA

Work Phone Number: 22220029

Monthly Salary in Local Currency (if employed): DOES NOT APPLY

Briefly Describe your Duties: STUDENT AT SCHOOL

Security and Background Information

Do you have a communicable disease of public health significance? (Communicable diseases of public significance NO

include chancroid, gonorrhea, granuloma inguinale, infectious leprosy, lymphogranuloma venereum, infectiousstage syphilis, active tuberculoiis, and others diseases as determined by the Department of Health and HumanServices.)

Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of Noyourself or others?

ttps://ceac.state.gov/GENNIV/common/printapplication.aspx?Pl HOdJwcnnROkWztqqlMWOMOxukFd. .. 3l

nn2 Consular Electronic Application Center - Print Application

Are you or have you ever been a drug abuser or addict?

Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, orother similar action?

Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?

Are you coming to the United States to engage in prostitution or unlawful commercialized vice or have you beenengaged in prostitution or procuring prostitutes within the past 10 years?

Have you ever been involved in, or do you seek to engage in, money laundering?

Have you ever committed or conspired to commit a human trafficking offense in the United States or outside theUnited States?

Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a humantrafficking offense in the United States or outside the United States and have you within the last five years,knowingly benefited from the trafficking activities?

Have you knowingly aided, abetted, assisted or colluded with an individual who has committed or conspired tocommit a severe human trafficking offense in the United States or outside the United States?

Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in theUnited States?

Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terroristactivities?

Have you ever or do you intend to provide financial assistance or other support to terrorists or terroristorganizations?

Are you a member or representative of a terrorist organization?

Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?

Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?

Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings,or other acts of violence?

Have you ever engaged in the recruitment or the use of the child soldiers?

Have you, while serving as a government official, been responsible for or directly carried out, at any time,particularly severe violations of religious freedom?

Have you ever been directly involved in the establishment or enforcement of the population controls forcing awoman to undergo an abor[ion against her free choice or a man or a woman to undergo sterilization against his orher free will?

Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue?

Have you ever been the subject of a removal or deportation hearing?

Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or any other UnitedStates immigration benefit by fraud or willful misrepresentation or other unlawful means?

Have you failed to attend a hearing on removability or inadmissibility within the last five years?

Have you ever been unlawfully present, overstayed the amount of time granted by an immigration official orotherwise violated the terms of a U.S. visa?

Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legalcustody by a U,S. court?

Have you voted in the United States in violation of any law or regulation?

Have you ever renounced United States citizenship for the purpose of avoiding taxation?

Have you attended a public elementary school on student (F) status or a public secondary school after November30, 1996 without reimbursing the school?

Location Information

Location where you will be submitting your application

Current Location:

Preparer of Application

CHISINAU, MOLDOVA

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

4tttps://ceac.state.gov/GENNIV/common/printapplication.aspx?Pl Hr0dJwcnnRokWztqqlMWOMOxukFd.. .

nh2 Consular Electronic Application Center - Print Application

Did anyone assist you in filling out this application?

Preparer Surnames:

Preparer Given Names:

Organization Name:

Street Address:

C itY:

State/Province r

Postal ZonelZIP Code:

Country:

Relationship to You:

YES

DROBENKO

JOHN

DOES NOT APPLY

23.30 31 AVENUE

ASTORIA

NEW YORK

11106

UNITED STATES OF AMERICA

RELATIVE

You electronically Signed your application on 07-Mar-20t2 09:49:46. You were required to electronically sign your applicationyourself, unless otherwise exempt by regulaUon, even if the application was prepared by someone other than yourself. Yourelectronic signature certifies that you have read and understood the questions in this application and that your answers are trueand correct to the best of your knowledge and belief. The submission of an application containing any false or misleadingstatements may result in the permanent refusal of a visa or the denial of entry into the United States. All declarations made inthis application are unsworn declarations made under penalty of perjury. (28 U.S.C. 1746).

The information that you have provided in your application and other information submitted with your application may beaccessible to other government agencies having statutory or other lawful authority to use such information, including for lawenforcement and immigration law enforcement purposes. The photograph that you provide with your application may be used foremployment verification or other U.S. law purposes.

5lttps://ceac.strate.gov/GENNIV/common/printapplication.aspx?Pl HildJwcnnROkWztqqlMWOMOxukFd...